The role of surgery in chronic constipation: when and why.

Constipation is the most frequent bowel dysfunction with paramount affects on people’s quality of life and mental wellness; it has been estimated that about 30% of people in western countries are afflicted by constipation (1) with heavy aftermath on the health national system. Constipation can be a primary disorder or secondary to neurological, pharmacological, depression, endocrine diseases or child abuse (2). Primary constipation is commonly distinguished in slow transit type, outlet obstruction or both, according to “Rome III Criteria” (3). Females of any age are more frequently affected by both these types of constipation. The incidence of true slow transit constipation in presence of a normal colon was overestimated in the past, whilst an increasing number of outlet obstruction constipation cases are now identified after the availability of new diagnostic procedures. Clinical work-up in patients with constipation should focus on the exclusion of organic or secondary causes of constipation by colonoscopy (or barium enema) and accurate anamnesis, followed by more specific functional investigations (colonic transit study by radiopaque markers for slow transit constipation, and dynamic defecography for outlet obstruction). Complementary investigations are anorectal manovolumetry (to exclude Hirschsprung’s disease and rectal hyposensitivity) and some autonomic tests to identify patients with autonomic neuropathy which will probably do not benefit from surgery (4). Another clue point in this work-up is the assessment of the severity of the disease using dedicated scoring systems [Wexner-Agachan score (5), KESS score (6), Altomare ODS score (7), PAC-SYM score (8)] and the evaluation of effects of the disease on patient’s quality of life [PAC QoL (9) and CRQoL (10)]. These evaluation have recently been introduced not only in clinical research but also in the clinical decision making process. Although constipation is mainly a medical problem, there are several cases which could benefit from surgery. A surgical approach to slow transit constipation dates back to the early Victorian age in England (11) where Arbuthnot Lane first performed successfully a total colectomy for constipation getting fame and honors (for this he was nominated Sir by her majesty the Queen Victoria). However this aggressive approach fall into disgrace when he’s theory of fecal autointoxication was revealed unsubstantiated and surgery for constipation was abandoned for more than 60 years. Nowadays colectomy and ileorectal anastomosis for treating slow transit constipation is considered the last option in a very selected group of patients when any other kind of treatments has failed and when the patient’s quality of life is severely compromised. For this type of constipation, beside polyethylene glycol based laxatives (12, 13, 14), an increasing number of new drugs have been experimented and are currently under trial, targeting different mechanisms of action like chloride-channel